Abhinandana Anantharaju

Response to treatment of hepatitis C in individuals with a recent history of intravenous drug abuse

OBJECTIVE:The aim of this study was to determine the rate of sustained response (SR) to high-dose daily interferon (IFN) therapy in prior drug abusers with chronic hepatitis C. This was a retrospective matched cohort study conducted at a tertiary care university hospital in a large urban area.METHODS:The 120 individuals in each cohort were treated by the same physicians at the same facility, using the same treatment protocol and management procedures. Each patient received 5 million units of IFN daily for at least 1 yr and usually longer.RESULTS:Both groups achieved a similar rate of SR (no i.v. drug abuse, 37% vs i.v. drug abuse, 33%). The end of treatment (ET) response rate was unexpectedly higher in the drug-abusing population as compared to that non–drug-abusing control subjects but fell during the follow-up period to achieve an SR similar to that of the non–drug-abusing controls. The side effects of IFN therapy were no greater in the prior drug abusing population than in the controls, although many in the drug-abusing group increased their dose of methadone to counteract IFN side effects.CONCLUSIONS:The SR rate achieved by intravenous drug abusers to high-dose, daily IFN is similar to that in a non–drug-abusing HCV positive population. Recent use of illicit drugs within a 6-month period of starting IFN therapy or continued methadone use during treatment does not seem to impair the response to IFN when the results are compared with those of a matched cohort of non–drug-abusing controls.

Bone mineral density among cirrhotic patients awaiting liver transplantation

Osteoporosis is an important and common complication in patients with chronic liver disease. The goal of this study was to determine the bone mineral density (BMD) in different subgroups among pretransplant cirrhotic patients. BMD of the lumbar vertebrae (L) and femoral neck (F) were obtained in 104 consecutive cirrhotic patients. Descriptive and inferential statistics were used to compare the BMD among various groups. The mean BMD in males (n = 54) and females (n = 50) at L were 1.28 ± 0.25 g/cm2 and 1.13 ± 0.20 g/cm2, respectively (P = .001); at F they were 1.03 ± 0.14 and 0.91 ± 0.17, respectively (P < .0001). Among males, BMD at L in Child‐Turcotte‐Pugh class B and C were 1.40 ± 0.21 and 1.13 ± 0.20, respectively (P = .001); at F they were 1.11 ± 0.10 and 0.93 ± 0.13, respectively (P < .0001). Among females, BMD at L in Child‐Turcotte‐Pugh class B and C were 1.27 ± 0.18 and 1.05 ± 0.16, respectively (P = .0003); at F they were 1.02 ± 0.16 and 0.83 ± 0.12, respectively (P = .001). The BMD in premenopausal females (n = 15) and postmenopausal females (n = 35) at L were 1.20 ± 0.19 and 1.11 ± 0.20, respectively (P = .15); at F they were 0.97 ± 0.17 and 0.88 ± 0.16, respectively (P = .12). The BMD in postmenopausal females on hormone replacement therapy (n = 19) and on no hormone replacement therapy (n = 16) at L were 1.07 ± 0.17 and 1.14 ± 0.23, respectively (P = .29); at F they were 0.85 ± 0.15 and 0.91 ± 0.18, respectively (P = .33). The BMD values between etiologic groups were not significantly different. The overall prevalence of osteopenia and osteoporosis were 34.6% and 11.5%, respectively, being significantly higher in females than in males. In conclusion, significant difference in BMD values exists between males and females, as well as between Child‐Turcotte‐Pugh class B and C patients with cirrhosis. In addition, there is no significant influence of menopausal status, hormone replacement therapy, and etiology of cirrhosis on BMD. (Liver Transpl 2004;10:648–653.)

Use of activated recombinant human factor VII (rhFVIIa) for colonic polypectomies in patients with cirrhosis and coagulopathy.

The prevalence of colonic polyps in patients with cirrhosis appears to be higher than that of the general population. The current practice for a polypectomy in a coagulopathic cirrhotic patient involves the reversal of the coagulopathy using fresh frozen plasma (FFP) prior to the polypectomy, usually at a second colonoscopy. The use of FFP is associated with many problems, particularly that of volume overload. Here we report four cases with advanced cirrhosis and severe coagulopathy that underwent polypectomies by snare cautery after an intravenous bolus infusion of recombinant human factor VIIa (rhFVIIa). The dose used was 120 microg/kg, which provided normalization of the coagulation parameters for 10-16 hr. The immediate use of rhFVIIa reduced the utilization of resources and enabled the performance of the polypectomies at the initial colonoscopy. No postpolypectomy bleeding was noted. The high cost of the drug is the only obstacle to a wider use of rhFVIIa for this purpose. The cost of the drug, however, is offset substantially by the cost of hospitalization for the administration of FFP, the cost of a second colonoscopy, and the charges associated with a second utilization of the endoscopy suite.

CASE REPORT: Acute Intracranial Hemorrhage in a Cirrhotic Controlled with Recombinant Factor VIIa

Human factor VIIa is a vitamin K-dependent glycoprotein consisting of 406 amino acids having a molecular weight of 50 kDa (1). Factor VIIa is the initiating factor in the conversion of prothrombin to thrombin via the extrinsic pathway (1). Specifically, factor VIIa forms a complex with tissue factor that activates factor X and factor IX, which in turn forms a multimolecular complex with factor V, which then converts prothrombin to thrombin on the surface of platelets with the resultant production of fibrin monomers. The resultant fibrin undergoes self-polymerization until a critical size is achieved and the protein becomes insoluble as the hemostatic plug or clot. Recently, recombinant human factor VIIa (rhFVIIa) has become commercially available for the treatment of hemophiliacs with antibodies to factor VIII or factor IX and individuals who are congenitally factor VIIdeficient (1). Even more recently, rhFVIIa has been used to control bleeding in cases of trauma in both hemophiliacs as well as nonhemophiliac patients (2–9). This use of rhFVIIa in surgical and trauma units has raised the possibility that rhFVIIa might also be clinically useful in other medical situations. Herein, we report a case of a 68-year-old man with a severe coagulopathy due to alcohol-associated cirrhosis, who experienced a spontaneous acute intracranial hemorrhage and was treated with rhFVIIa with cessation of the intracranial bleeding with clinical and radiological stabilization of his intracranial injury.

CASE REPORT: Transverse Myelitis Occurring in Association with Primary Biliary Cirrhosis and Sjogren's Syndrome

Transverse myelitis (TM) as a manifestation of an autoimmune disorder is relatively rare. In Sjogrens syndrome (SS), the occurrence of TM is remarkably uncommon. Only three cases have been reported associated with primary biliary cirrhosis (PBC). Here we report the fourth case of TM occurring in association with SS and PBC. Patients with unexplained transverse myelitis require a careful search for an underlying etiology to include the findings of SS and PBC. The precise pathogenesis of TM in patients with SS is unknown. Most show good response to steroids. Cyclophosphamide and chlorambucil may be useful in those who respond poorly to steroids.

Posttransplantation lymphoproliferative disorder

A 29-year-old woman with cystic fibrosis presented with abdominal pain, which had worsened over 3 days, together with low-grade fever and chills. The pain, which radiated from the central to the lower abdomen, increased with movement and had been present since bilateral lung transplantation 4months earlier. She had occasional nausea and nonbilious vomiting. The medical history included laparotomy for postoperative small bowel obstruction, diabetes mellitus, and osteoporosis. Medications included metoclopramide, lactulose, prednisone, tacrolimus, azathioprine, valacyclovir, itraconazole, cotrimoxazole, alendronate, lansoprazole, pancreatic enzymes, insulin, calcium, folate, and a multivitamin. Examination was normal except for mild periumbilical tenderness. Laboratory tests revealed mild anemia and a slight nonanion gap acidosis. Two small duodenal ulcers were discovered at EGD. Biopsy specimens revealed mild duodenitis with superficial ulceration. At

High dose interferon alpha monotherapy in patients with chronic hepatitis C and normal alanine aminotransferase level

High dose interferon alpha monotherapy in patients with chronic hepatitis C and normal alanine aminotransferase level

Nonocclusive mesenteric ischemia: reality

1. Kadono J, Hamada N, Ishizaki N, Shibuya H, Tanaka K, Horinouchi M, et al. Recurrent nonocclusive mesenteric ischemia after resection of iliac artery aneurysm. J Gastroenterol 2002; 37:123–8. 2. Lefrancois C, Derlon A, Le Querrec A, Justum AM, Gautier P, Maurel J, et al. Mesenteric venous thrombosis. Risk factors, treatment and outcome. An analysis of 18 cases (in French with English abstract). Ann Fr Anesth Reanim 1994;13:182–94. The recent article by Kadono et al.1 published in the Journal of Gastroenterology describes an unfortunate patient who succumbed to multiple episodes of presumed bowel ischemia. The authors attributed the events to nonocclusive mesenteric ischemia (NOMI). This diagnosis, however, appears to be presumptive rather than definite, as other causes have not been evaluated and ruled out on the basis of negative data. The following are some specific concerns regarding the case as presented: